Widow's or Widower's Insurance Benefits Application Form
(Month, year)(Month, year)
Form SSA-10 (05-2014) EF (05-2014)
Destroy Prior Editions
APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*
Form Approved
OMB No. 0960-0004
Page 1
TEL
TOE 120/145/155
With this application, you are applying for all insurance benefits for which you are eligible under
Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health
Insurance for the Aged and Disabled) of the Social Security Act as presently amended. The
information you furnish on this application will ordinarily be sufficient for a determination on the
lump-sum death payment.
If you were receiving spouse's benefits at the time of your spouse's death, you only need to
complete the circled items. All other claimants must complete the entire form.
*This may also be considered an application for survivors benefits under the Railroad Retirement
Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter
13 (which is, as such, an application for other types of death benefits under title 38).
(Do not write in
this space)
1. (a) PRINT name of deceased wage earner or
self-employed person (herein referred to as
the "deceased")
(b) Check (X) one for the deceased
(a) PRINT your name
(c) Enter your name at birth if different from item 2(a)
PART I - INFORMATION ABOUT THE DECEASED
Enter date of birth of deceased MONTH, DAY, YEAR
(a) Enter date of death MONTH, DAY, YEAR
(b) Enter place of death
CITY AND STATE
Enter name of the State or foreign country where the deceased had a fixed,
permanent home at the time of death.
(a) Did the deceased ever file an application for Social Security benefits, a
period of disability under Social Security, supplemental security income, or
hospital or medical insurance under Medicare? If unknown, check this box
(If "No," go
on to item 7.)
(b) Enter name(s) of person(s) on whose Social
Security record(s) other application was filed.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter Social Security Number(s) of person(s) named in (b).
Answer Item 7 Only if the Deceased Died Prior to Full Retirement Age or Prior to 1 Year Past Full Retirement Age,
and Within the Past 4 Months.
(a) Was the deceased unable to work because of illnesses, injuries or conditions
at the time of death?
(If "No," go on
to item 8.)
MONTH, DAY, YEAR
(If "No," go on
to item 9.)
(b) Enter dates of service.
FROM: TO:
(c) Has anyone (including the deceased) received, or does anyone expect to
receive, a benefit from any other Federal agency?
(Over)
SOCIAL SECURITY ADMINISTRATION
2.
3.
4.
(If "Yes," answer
(b) and (c).)
5.
7.
6.
(If "Yes,"
answer (b).)
(b) Enter the date the deceased became unable to work.
(a) Was the deceased in the active military or naval service (including
Reserve or National Guard active duty or active duty for training) after
September 7, 1939 and before 1968?
8.
(If "Yes," answer
(b) and (c).)
Male Female
FIRST NAME, MIDDLE INITIAL, LAST NAME
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter deceased's Social Security Number
(b) Enter your Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
Yes
No
Yes
No
Yes No
Yes No
If unknown, check this block
Page 1/8
Free Download
Widow's or Widower's Insurance Benefits Application Form PDF
Favor this template? Just fancy it by voting!
(1 Votes)
5.0
Related Forms
2 Page(s) | 1289 Views | 10 Downloads